Home is Where the Health Is

WASHINGTON -- Greater investment in permanent supportive housing is critical to improving health outcomes, according to health and housing experts who spoke at a recent Senate briefing.

"As healthcare providers, nothing that we do works well when someone is living on the street," said Barbara DiPietro, PhD, director of policy for the National Health Care for the Homeless Council, an advocacy network based in Nashville, Tenn.

When a person completes a month-long treatment program for a behavioral issue, or has a wound treated and bandaged, and is then discharged to the street or a homeless shelter, "we have complicated and compromised the treatment we just invested in," she said.

Harsh weather conditions combined with the stress that homeless people endure can exacerbate any illness. "If you didn't have [health] issues before you tend to develop issues when you are homeless."

Homeless people have 3 to 6 times the rate of chronic disease as non-homeless people, DiPietro said. And providers see both extremes in patient access: the frequent user who visits the hospital without cause and the patient on the fringe of society, often someone coping with a mental health or substance abuse problem, who avoids the healthcare system altogether.

Health problems can also lead to homelessness. After a serious illness or injury often people will have difficulty returning to work and many will lose their jobs. Without a steady income, they cannot meet the rent or mortgage payments and be forced to give up their homes as well, DiPietro said.

Peer-reviewed studies consistently show that having housing improves health, boosts health outcomes, and lowers the total cost of healthcare, DiPietro, stated, but added that federal support is necessary to deliver these improved outcomes.

"We really want to re-orient housing as a healthcare intervention that we really need," she said.

Pilot programs such as the Frequent Users of Systems Engagement (FUSE) offer one solution by providing supportive care that integrates both health and housing components, said Sister Adele O'Sullivan, CSJ, MD, medical director of Circle the City, a Phoenix-based nonprofit organization. O'Sullivan's center, which is located in Maricopa County, Ariz., participated in the FUSE program which has been implemented in six other cities including Los Angeles and Detroit.

In Arizona, the chronically homeless population fell by 15% from 2013 to 2014, said O'Sullivan. Medicaid expansion was adopted by the state in 2013. However, the state's Medicaid plan offered supportive housing services only to people with serious mental illness. A large part of the decline in homelessness is due to programs like FUSE, she said. Her organization, which offers "bridge housing" gives homeless patients a temporary space to "recuperate" and have their medical needs met, while connecting them with housing resources.

In Maricopa County, the program yielded a 73% reduction in emergency department (ED) visits and a 74% reduction in inpatient utilization for high acuity or high use individuals with mental health and substance abuse problems, once a patient had been given permanent supportive housing, O'Sullivan said.

At Circle the City, one homeless patient visited a single local hospital 192 times and accumulated charges of $358,000 from 2007 to 2013. But hospital staff did not officially ever admit the patient.

Since 2013, after spending 3 weeks in the Circle the City's medical respite program, and then receiving permanent supportive housing, that same patient visited the ED twice, and both visits were deemed. Today, he is receiving care for a traumatic brain injury at a nearby clinic and working part-time at a local restaurant, O'Sullivan reported.

"When we can get those wraparound services, those positive outcomes that people think aren't possible, I'm here to tell you they're possible," she said.

Jennifer Ho, senior advisor for housing and services for the Department of Housing and Urban Development (HUD), said she's seen "unprecedented" collaboration between the Centers for Medicare and Medicaid Services and her agency. However, in the current fiscal environment, "we're not doing what we know works and we're not doing anything at scale that matches the need."

Just among the U.S. aging population, housing is inadequate, Ho said. HUD currently offers housing to 1.2 million seniors, but that number represents only a third of the eligible seniors. Ho cited a Harvard University report that estimates the number of elderly households will increase by 2.6 million from 2011 to 2030. Around 900,000 new subsidized housing units would be needed to maintain the status quo and support even a third of these seniors, she said.

President Obama's 2016 budget included enough funding to increase supportive housing to levels that would reduce chronic homelessness. However, "there is not consensus that this is an investment the federal government should be making," Ho said.

Earlier this summer, a Senate mark-up made a 93% cut to the HUD HOME investment program, from $900 million to $66 million in fiscal year 2016.

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